Slip and Fall Incident Report
Property Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date of Incident
*
-
Month
-
Day
Year
Date
Time of Incident
*
Hour Minutes
AM
PM
AM/PM Option
Injured Person Information
Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Employer (if applicable)
Job Title (if applicable)
Incident Details
Location of Incident (specific area in the property)
*
Describe what happened (as reported by the injured person)
*
Conditions at the Time of Incident
Weather conditions (if applicable)
Lighting conditions
*
Floor condition (wet, dry, uneven etc.)
*
Presence of any hazards (spills, loose carpeting, ice, obstacles, etc.)
*
Witness Information (if any)
Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Statement (summarized):
Actions Taken
Was Medical assistance provided?
*
Yes
No
If yes, by whom? (EMS, Doctor, Property Staff, etc.)
Was the injured person able to leave on their own, or were they transported for medical care?
*
Did they refuse medical attention?
*
Yes
No
Photos & Evidence
Were photos taken?
*
Yes
No
Was video footage reviewed?
*
Yes
No
Report Completed By:
Name
*
First Name
Last Name
Signature
*
Continue
Continue
Should be Empty: